Provider Demographics
NPI:1629636097
Name:METTENBRINK, DEREK CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:CHARLES
Last Name:METTENBRINK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4256 DIAGON LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5306
Mailing Address - Country:US
Mailing Address - Phone:308-380-5938
Mailing Address - Fax:
Practice Address - Street 1:3020 S RESERVE ST STE D
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7652
Practice Address - Country:US
Practice Address - Phone:406-541-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE75351223P0221X
MTDEN-DEN-LIC-192451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry